2Departments of Cardiac and Vascular Sciences and Clinical Neuroscience, St George’s Medical School

ahalliday{at}sgul.ac.uk

Carotid artery stenting is not yet ready to replace endarterectomy

Carotid endarterectomy is currently the most effective intervention to prevent stroke in patients with recent symptoms of carotid stenosis.12 It also prevents future stroke in younger patients (under 75 years) who have not yet had symptoms, as long as the risk of stroke and death from surgery is not more than 3%.34

Patients naturally prefer carotid artery stenting to open surgery, but stenting has not been shown to be acceptably safe in clinical trials. Carotid endarterectomy has been in widespread use for more than 50 years, but carotid artery stenting is a more recent development. In the linked systematic review (doi:10.1136/bmj.c467), Meier and colleagues assessed the short term safety and intermediate term efficacy of carotid endarterectomy versus carotid artery stenting. They found that the short term (30 day) hazards of stroke and death after stenting in recent trials of symptomatic patients have improved but are not yet as good as those seen after surgery.5 In the intermediate term, the two treatments did not differ significantly for stroke or death (hazard ratio 0.90, 95% confidence interval 0.74 to 1.1).

In the most recent trial included in the systematic review, the International Carotid Stenting Study (ICSS), surgery was significantly less likely …